Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
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Friday, June 28, 2013

We don't shy away from controversy here at Shrink Rap, and today, child psychiatrist Dr. Mota-Castillo joins us to discuss the idea that children with bipolar disorder are being misdiagnosed with attention deficit disorder and then being inappropriately treated with stimulants, which may be causing them more harm than good. I've already written about my thoughts on the diagnosis of Bipolar Disorder as a catch-all category, and if you'd like to revisit that, seemy article onRethinking Bipolarity in Clinical Psychiatry News. And now for our guest blogger:

* * * * *

Does the APA have “The Belle
Indifference”?

In 2003 I began to
make noises (1) trying to get the attention of the American
Psychiatric Association (APA) and the American Academy of Child &
Adolescent Psychiatry (AACAP) but 10 years later, as should be expected from
those social clubs, they have ignored not only this former anchorman from
Dominican Republic but also some of their more prominent members.(2)

Today
I want to turn my requests (many of them) into a public and formal demand for
an explanation of a lack of action that, in my view, borders with
complicity.Earlier this year (3) one
of my favorite authors, Dr. S. Nassir Ghaemi pointed out a reality that many
try to hide: like other human beings we make mistakes. These are some of his
words:

“This
false sense of simplicity hides a complex truth: We have lost the ability to
accurately recognize our patients’ signs and symptoms; hence, we routinely
misdiagnose, then we mistreat. And throughout the process, we have little clue
that we might be wrong. And most of the blame has to do with DSM-III onward:
simplistic criteria that are often wrong, partly because they are explicitly
non–research-based; and when they might be right, DSM’s baleful influence of
being a teaching tool, replacing careful phenomenology, has dumbed down the
clinical capacities of my generation.”

I can’t express my
thoughts with the artful use of the English language that Nassir has but if you
can show your stoicism by putting up with my linguistic flaws maybe I would be
able to get your attention to a very serious problem, persistently ignored by
the APA and the AACAP.They are
morally obligated to intervene because I have seen doctors coming out of
training and still supporting concepts that have been outdated for decades,
i.e. “children don’t get bipolar.”

These two organizations are also guilty
of ignoring the concept of bipolar spectrum which could help trainees and
families to understand that, similar to a Chihuahua and a Pitbull (both called
dog) two individuals with bipolar spectrum disorder could look completely
different. This is important because mood and anxiety disorders are frequently
misdiagnosed as Attention-Deficit Hyperactivity Disorder (ADHD).

There is so much to say and so little
time to read that I will present several brief real cases (demographic changed
for privacy) and let you, the reader, to be the jury…should the APA and the
AACAP be morally indicted or I am missing something here?

I realize that it will hard to believe
but here is the awful truth: These patients are a small % of many others in a single week.

1-Two
brothers taking an amphetamine drug for several years while having almost daily
physical altercations and failing in school. On examination both had auditory
hallucinations and insomnia. Father is an untreated bipolar who requested to be
enrolled in treatment after he witnessed the transformation of his children in
just 3 weeks without stimulants and on a mood stabilizer plus 1 mg of the
antipsychotic drug risperidone.

2-Sixth
grader girl that repeated the 5th grade while taking a high dose of
amphetamines (started in 1st grade) was having frequent arguments
with teachers and her grandmother. She admitted to “be tired of been angry all the time” and
said that she requested to a previous doctor a change in medication because “my
mother is bipolar and my father is in prison because he killed somebody.” I
should point out that this patient does not have one single “ADHD symptom” that
could not be explained by her racing thoughts, impulsivity and mood swings.

3-A girl in
elementary school (Special Education) with Autism has been on methylphenidate
(the famous Ritalin) for almost 2 years despite severe obsessive behaviors and
a parent with bipolar disorder. A “comprehensive evaluation” at a teaching
hospital kept the ADHD diagnosis despite the DSM restriction in the presence of
autism. 4 psychiatrists and 1 psychologist failed to detect the link between
the escalating aggression and obsessions and the stimulant drug she was taken.

4-Another
elementary school student walk into my office and could not stop talking and
clowning around. Without asking permission he moved 3 small chairs to place
them in a perfect alignment and when I pointed this out to the father the
answer was:“at home it is the
same, everything has to be in perfect order.” The father also reported that
Obsessive-Compulsive Disorder (OCD) runs in his family and welcomed the idea of
replacing the amphetamine with the anti-anxiety medication citalopram.

5-A mother
described her child as “a slow learner that does not understand right from
wrong, that gets into everything and who acts out a lot.”This unfortunate case of Mild Mental Retardation
(also a categorical no from diagnostic manual (DSM) to diagnose ADHD) was also
taken a brand of methylphenidate even though the weight loss was persistent and
the insomnia severe.

As
I said before, I want to keep your attention and for that reason I will invite
to those that want to hear about the hundreds of similar missed diagnoses to
contact me and I will be glad to answer their questions. For now I want to end
by reporting that I have seen children and adolescents with Social Anxiety
Disorder, Post-Traumatic Stress Disorder, Absence Seizures, Generalized Anxiety
Disorder, malnutrition and etc., in addition to those that are more commonly
confused with ADHD such as OCD and bipolar spectrum disorder.

And
one final question:If it is not
the APA or the AACAP who else can fix this problem?

33
comments:

1. You are right that other disorders are often misdiagnosed as ADHD, but I think this is something that most child psychiatrists I know are aware of.

2. I find it ironic that you lament over-diagnosis of ADHD while promoting the notion of the bipolar spectrum in kids. Just because a kid has aggression and tantrums, and reacts poorly to stimulants but gets better with risperidone, does not make it bipolar. See here and here for more of my thoughts on childhood bipolar.

3. With DSM-5, there is no longer an exclusion for diagnosing ADHD if someone also has an autism spectrum disorder diagnosis.

I guess it depends on what the special interest is of the clinician, right? Yes, I am being sarcastic.

Maybe the real truth is that psychiatric conditions in general are way overdiagnosed. But that seems to be a truth that no one in psychiatry wants to hear and instead attributes statements like that to people simply being an antipsychiatry nut.

AA

PS - In case anyone has forgotten, bipolar reactions are a side effect of stimulants and should not be solely used to diagnose BP without taking a complete history of the patient.

In my opinion, what is wrong in situations such as you describe is that doctors are overly quick to diagnose, do not spend enough time listening to the patient, and are overly quick in prescribing psychiatric drugs.

What surprised me about this article was how quickly the author puts the patients he views as incorrectly medicated onto different medications. The author is as quick to diagnose and as quick to medicate as the previous doctors.

Might not some of the presenting symptoms you observe be caused by the amphetamines? Why do you not use a very slow ramp-down schedule off the stimulants the kids are on, then evaluate each child by meeting with him or her for several hours, once or twice a week, AFTER the child is free of stimulants?

I feel sorry for the children you describe, being medicated with one drug, then another, and nobody spending the time to diagnose, including you.

Who can fix this problem? Each and every psychiatrist can, by increasing time spent talking and observing, not putting words in patients mouths, and not making snap judgements based on limited observations. Insurance companies are also part of the problem because they reward the ten-minute diagnose and medicate doctors preferentially.

The purpose of my article was to start a discussion based on reason, not in passion. Yesterday, the temperature in the Death Valley, CA was 130 degrees but records show that such high numbers were surpassed 100 years ago when the temperature reached 134 degrees. A Global Warming Denier can say “You see? There is no such thing as Global Warming, and here is the proof”. Those that only look at “on leg of the elephant” could believe it. The statement becomes a fallacy when you think that now we are observing a persistent trend of raising temperatures and higher frequency of natural disasters while the 1913 overheat was an isolated event. The child that I diagnosed with bipolar disorder at the age of 25 months is now 16 and still bipolar (Journal of Affective Disorders. Find it by searching my name followed by “very young children divalproex acid) and the 8 year-old that was hallucinating in 2001 (and showing violent behaviors) while taking Ritalin is now a young man and still my patient. If you find the Commentary (Psychiatric Times) “The crisis of Overdiagnosed ADHD” you could see that family Hx was consistent with my diagnosis. I do not ever change one label for another just for the sake of medicating children. I practice responsible medicine and offer to every person the treatment that he or she needs.

Regarding the time I expend with my patient to make a diagnosis I have the satisfaction of listening to expressions such as “this is the first time that anybody actually has spent time talking to my son and asking questions about his family” at least twice a week. On the other hand, the record speaks by itself: My patients get better on a very high percentage.

With regard to “quick to diagnose” I believe the opposite. Many famous people would be alive or out of legal troubles should they have engaged in treatment with medications and psychotherapy instead of using alcohol or pain killers as self-prescribed “mind soothers.” As I said before, why does society feel comfortable when a toddler has been diagnosed with a brain tumor, but feel uneasy when a 7 year-old gets the same label that one (and sometimes both) parents have?

Please, give me facts, not emotions, and if a group of doctors were blind-sided by the irrationality of allowing the diagnosis of ADHD in an autistic (not expected to pay attention) person, that does not make it a credible fact. Remember that many of the Global Warming deniers are prominent scientists too.

Dr. Mota-Castillo described five cases. In one he changed the medication. In another he brought up to the father the idea of trying citalopram. That means he changed medications in one case out of five, considered it in another. He does not say how quickly he made these suggestions nor how much time was spent in evaluation.

Yet Sunny CA notes above "how quickly the author puts the patients he views as incorrectly medicated onto different medications. The author is as quick to diagnose and as quick to medicate as the previous doctors."

Among the most common responses here on Shrink Rap are those that vastly overgeneralize from data given, extrapolate from one's very limited experience to how all psychiatrists think, declare what all mental health facilities do, or how all hospital staff treat patients. Experience with (at most) a few practitioners is turned into "what psychiatry does is..."

I found Dr. Mota-Castillo's piece thought provoking. He challenges general conceptions and thinks that misdiagnosis has led to many patients being improperly treated with stimulants. He has a lot of experience and it is clear that he could give many examples that make the same point. There have been numerous articles in major newspapers bringing up this issue, too. Here on Shrink Rap many psychiatrists have complained of the effects on psychiatric thinking and practice caused by very simplistic diagnostic criteria.

Fairly? What have the truth has to do with credentials? The surgeon that cut the wrong leg was not only Board-Certified by in the faculty of a teaching hospital. I got mine because it was a requirement to obtain privileges at a hospital but I will never apply for Certification in C&A and put myself in the situation of having a wise guy asking me to define diagnoses that are unsubstantiated such as Conduct Disorder and Oppositional-Defiant Disorder. If you can show evidence that I have ever applied for the Certification in C&A please do so. By the way a fair disclosure would be to sign a personal attack with a real name...or to say something with scientific foundation.

Hello Dr Mota-Castillo,I notice your blogger profile lists geriatric psychiatry as one of your occupations. Do you have any special fellowship training or board certification in geriatric psychiatry?Also, is it unusual for one to be both a child psychiatrist and a geriatric psychiatrist?Also, thank you for this article.

Dr. Mota-Castillo, I am very disappointed that someone with your reputation is using a strawman argument by stating that people who express concern about the overdiagnosis of BP in kids are deniers. By the way, many of your colleagues have also expressed the same concern, including Allen Frances, so I guess there alot of deniers in psychiatry.

By the way, as someone who claims they operate on facts, I didn't see any in your response. I have alots of questions about how you diagnose a kid with BP but I will stick to this one. Since the symptoms of autistic spectrum disorder can easily look like bipolar disorder, what steps do you take to rule that out?

Jesse - With all due respect, providing case histories does nothing to explain how a psychiatrist comes to make a diagnosis. I believe that is why that is called anecdotal evidence in medical journals.

I will have to assume that Anonymous Anonymous (AA) didn’t read this paragraph: For now I want to end by reporting that I have seen children and adolescents with Social Anxiety Disorder, Post-Traumatic Stress Disorder, Absence Seizures, Generalized Anxiety Disorder, malnutrition and etc., in addition to those that are more commonly confused with ADHD such as OCD and bipolar spectrum disorder.My favorite diagnosis is the one the patient has because I practice medicine with objectivity and with social responsibility. This will be my last response to an anonymous posting because I am not going to fall into the trap of shifting the conversation from the failure of the APA and AACAP to guide the practice of psychiatry in the USA. I am not going to discuss my credentials or the fallacy that prominent people can’t make mistakes but, because no everybody in this forum is a physician I will said that it is common for psychiatrists to be involved (and Certified too) in several sub-specialties. For example Vinod Patel (Phoenix, AZ) has 4 certifications and Mark Rubin is a psychiatrist and a pediatrician. Regarding how I diagnose a child with bipolar spectrum disorder this is the answer: I listen to what the parents, guardian or grandparents report as behaviors that are creating problems to the child. I observe the child demeanor and interaction with me and other adults in the room, ask questions that most clinician ignore: speed of the mind, hallucinations, family history of aggressive behaviors, alcoholism or drug addition, time of the day “when you feel that your brain can think better” (morning, lunch time or afternoon?), how long it takes to fall sleep, etc. But probably the most important tool I have is that I don’t diagnose Oppositional-Defiant Disorder (ODD) and instead try to understand why a child refusing to comply with what the adults are expecting from him or her. At time it is Social Anxiety Disorder behind a refusal to attend school but it could be Obsessive-Compulsive Disorder what triggers a rage episode when something has been changed. In other cases it is an elevated mood that makes the patient believes that he or she does not have to obey “this person that is equal to me.” Of course, if you believe that ODD is a diagnosis instead of a symptom then you probably are going to blame the child for not getting better “despite adequate treatment.” Frequently “adequate” means 40 mg of an amphetamine for a 35 lbs boy with OCD, who is having all the side effects this type of drug can induce, including the worsening of the obsessions. By the way, this is why autistic children get worse with stimulants…all of them (100%) have obsessions. To conclude, you said that symptoms of Autistic Spectrum Disorder can look like those of bipolar spectrum disorder and that is a misunderstanding of both conditions: Autistic children avoid social interactions while bipolar individuals are either “social butterflies” or react with hostility to regular conversations…but react. They are not indifferent. One more thing, do you call anecdotal the report of hundreds of cases? Have you read my presentations are the US Psychiatrist Congress? Let’s keep the conversation around the central issue and join me in holding the APA and the AACAP for no questioning statistical atrocities such as this one: 90-95% of psychiatrists diagnose 8-9 of every patient that come to their office with one diagnosis: ADHD. These 2 organizations are also silent about thousands of their members who write in a report “denies auditory hallucinations” when they never asked a question about this issue and in multiple cases the patient had been “hearing voices” for years. One outrageous case was the one of a child born in a Psychiatric Hospital when both parents were patients (schizophrenia) and adopted by a very nice family that took him to a teaching hospital in NYC where he was diagnosed ADHD and given Ritalin even though the complaint was that “he was ripping off the house”, could not fall sleep before midnight and was hurting the house’s pets.

If not the APA or AACAP, then who will fix these problems? Psychiatrists who do not belong to organizations that do not seem to care there are problems!

And this comment above, I do not get the reference: "90-95% of psychiatrists diagnose 8-9 of every patient that come to their office with one diagnosis: ADHD."

Please clarify what you meant, because you might have a point there is overdiagnosis of ADD going on, but, even I do not think psychiatrists are diagnosing more than 20% of their total patient load with ADD. There are those trying to illicitly get stimulants, and that is a serious issue, but, maybe it is time for doctors to set stronger limits to get such prescriptions.

Frankly, I don't get the point of this post in the first place. For a commenter above to challenge if the author has a place in doing predominate work in C&A without the subspecialty training, well, is that appropriate?

wow- dr mota-castillo, you sure show some anger in your responses- those 2 names you mentioned- i looked them up- the first shows 3 certificates, not 4-- and the 2nd does not seem to be a pediatrician like you say--- so your credibility is suffering here-- and i do think you might be the only child psychiatrist in the country also considering themself a geriatric psychiatrist--and, wheat evidence do you have that psychiatrists say no hallucinations without ever asking the question?--you really don't seem to be a fan of the scientific method if your answer is the patient simply said the question wasn't asked

Dr.Hassman: I do have the training in C&A and several times I have taken over clinics where almost 100% of the patients had an ADHD diagnosis. The point of the posting is to state that one "Superior Power" has to delineate rules and oversee the Training Programs. Old dogs are not going to learn new tricks and I am looking long term because human behavior and idiosyncratic thinking cannot be changed by Executive Orders.My eye-opener happened in 1996 when I became the first psychiatric for the special unit called Encanto within the Arizona Dep. Of Juvenile Corrections. 32 beds for youths with psychiatric diagnoses. I reviewed cases that had reports from up to 6 psychiatrists and despite charges of assault, even behind bars, they were taking stimulants. Among then was a 16 year-old that I found “feeding chicken-turkeys” and hearing several voices. The hallucinations were difficult to control because of so many years of stimulants but he got better and was released in an atmosphere of tears and hugs from teachers and therapists.I don’t have any hidden agenda but I am one of those people that can’t remain silent when witnessing injustice. I perceive as very unfair to children that ADHD has become the Dx of first choice instead of one that is given when other possible explanation of the symptoms have been excluded…like we do in medicine. Abdominal pain is a symptom not a diagnosis and likewise decreased attention span and hyperactivity are symptoms not a diagnosis.

Ms. Goodgirl: It is sad that instead of elevating the conversation you go to the personal level. Dr. Mark Rubin was my Medical Director from 1996-98 and you searched his profile. He was not practicing Pediatrics when I was in AZ but he trained in that specialty. Do you have an opinion about the poor job some Training programs are doing in teaching C & A psychiatric Residents how to arrive to a correct diagnosis and the APA’s inaction to solve this problem?

I've had a lot of thoughts on this post since it was first posted. I didn't respond because of lack of internet access outside of my phone. It's not a text friendly phone.

I think what makes this post makes me cringe actually has more to do with how it is written. When I read it, I was thinking, I don't understand how someone can be a board certified psychiatrist and have a poor grasp of the English language. It actually brought out hostile feelings in me. If you need your daughter to help you write posts...I just don't understand how you can get certification to work as a psychiatrist. I'm not writing this out of any kind of racism or hostility towards people who are ESL speakers. But I notice there have been a lot of questioning about the author's credentials, and I wonder if this is part of the reason why.

I have no problem with people speaking limited English in professions that don't require advanced language skills. But I would think psychiatry would demand that.

One of the worst instances with this kind of a problem was when I was in college and taking a history class. The TA was a grad student from a non-English speaking country. It was a history course and we were the Middle East. When she asked a student in the Discussion portion of the class what branch of some random government we were discussing that day, the student responded, "Judicial." The TA said, "No". I said, "Legal." She smiled and said, "That's correct."

If you are teaching in a history dept. and don't know the word judicial...then you shouldn't be working there. I consider it just as cringe worthy when I see a post written like this from a board certified psychiatrist.

Know what else is also misdiagnosed as ADHD and Bipolar? Acting out and PTSD as a result of abuse at home. Parents are never going to admit to the abuse. Kids don't admit to it because they're afraid of being taken out of the home. It's a huge problem, and one psychologists never want to consider. Easier to ply kids with medications to dull their minds than address the underlying issue.

1. Is it possible that the hallucinations and hostility experienced by the two brothers could have been caused by sleep deprivation secondary to stimulant use? How do you tell it's bipolar disorder when they're not sleeping due to stimulant use? 2. In the second scenario the 6th grader had "racing thoughts, impulsivity and mood swings;" she was on high dose stimulants; mom is bipolar and dad is in prison. How does one distinguish the effect of chaotic family life + use of high dose stimulants, from a mental disorder? 3. Was the third child subsequently diagnosed with bipolar disorder, if so what led to this diagnosis? I can definitely see how stimulant use can lead to aggression and obsessive behaviors, but wouldn't that just mean that this child's behavior could have been iatrogenic? 4.The fourth child could not stop talking and clowning around; he moved 3 small chairs to place them in a perfect alignment and when I pointed this out to the father the answer was: “at home it is the same, everything has to be in perfect order.” Even though the child has a family history of OCD, since stimulants can also cause these sorts of behaviors, how do you distinguish the effect of the drug from an actual disorder like OCD or anxiety?

I think the scenarios raised so many questions for me, because so much data was missing from the stories. As others have pointed out, we don't know much about the families these children come from. Also, how does a psychiatrist determine someone has a mental disorder when they're hyped up on a lot of stimulants?

I was not going to respond to any personal attack but the one by Jane I see it as a teaching moment for those that believe that foreigners think with an accent. When I read her questioning to the Board of Psychiatry and Neurology for certifying individuals with English as second language my reaction was to laugh and to recall the HBO movie “You Don’t Know Jack.”Apart from the fact that I didn’t get any help with the original posting, I credited my youngest daughter for reviewing my response because she is Copy Editor of her HS newspaper and I thought that her Journalism teacher would like that. This is relevant because what I want is to use this opportunity to remind the followers of this blog that, as Dr. Ronald Pies would say, everything has two handles. The reality is that my patients consider me an excellent communicator despite my accent and my mistakes constructing phrases. Frequently I have to repeat or to spell a word but I have a vocabulary that many times surpasses the limits of USA-born patients. Furthermore, because I have an excellent command of Spanish I am very aware of the importance of using proper language when I communicate in English or French.My advice, not as a psychiatrist or a former journalist but as a grandfather: Always consider more than one possibility. Never shoot from the hip…investigate a little bit about the person or institution you are about to criticize. For example, even though you will find hard to believe it students have written letters to the Dean requesting to have me back as a lecturer, not because of my English but for the reason that I can explain difficult subjects in simple terms…and that is one the requirement to be a good psychiatrist.Happy Independence Day for everybody.

@Jane - you are addressing an issue I wondered about quite a bit in the past. My own interest is primarily in psychotherapy, I was an English major in college, and I have studied several European languages (am fluent in one) in addition to three ancient ones. For years I had the same views you express. Here in Baltimore there are psychiatrists from all over the world, and I doubted that my colleagues from China and India could understand their patients as well as I could.

I was completely wrong. The ability to understand verbal communication and interact effectively is different from that of writing perfectly.

Dr. Mota wrote "I can’t express my thoughts with the artful use of the English language that Nassir has but if you can show your stoicism by putting up with my linguistic flaws".... This is a man with a sophisticated and learned knowledge of English. While he uses it in an idiomatic way that shows he is not a native speaker, I have no doubt as to his comprehension and ability to interact with his patients. Many of those patients, BTW, may be speaking to him in Spanish!

That is a funny example you gave about the history professor. The error about "judicial" made by a native of the middle east: perhaps she mistook it for "judaic" and so quickly said "no." She may be still laughing about that error regarding the "judaic" branch of government!

I am a psychotherapist who has been working in private practice, the prison system, a psychiatric hospital and with the courts. I have worked with parents and families for over 25 years and have tried to educate parents so they can be better consumers and not just agree with the medical professionals, often the pediatrician, who diagnoses and treats a child for ADHD when there are so many other things that are going on! For instance, when a family is going through a crisis, such as divorce, why are we medicating and/or treating the child and not the parents?? Unless Mom and Dad are getting help, I refuse to make the child the identified patient! What if the child is having difficulty assimilating all the stimuli around him/her? Could we try looking at the sensory system first before putting the child on stimulants!? I also cannot tell you how many parents know nothing about their family history when it comes to mental illness and how astounding it is to me that doctors are not gathering a lot of history before diagnosing a child! There is such relief when parents do start asking questions from their family of origin, or are even asked the correct questions about themselves. Generally people just think this is part of my personality and the way I am, not that there might be some reason or even something that could help them. Yes it is normal to get upset or angry- but not to the point that you punch holes in walls, or run people off the road! Then these children grow up and get put on antidepressants which exacerbates their symptoms, and so we pass it all along to another generation. I have been wearing myself out trying to educate the legal system but have come to the conclusion that the legal system supports crazy people and some of them are on the bench!! Robin Siebold, Ph.D., LMHC, Psychotherapist, Melbourne, Florida

As a mental health professional who serves children, I have have seen innumerable cases of what I have learned (through DSM)is likely a misdiagnosis of ADHD. The correct diagnosis may not necessarily be a mood disorder, but too often is a diagnosis for which amphetamines have caused much harm. I find this heinous; I have seen the behavioral effects for which children are blamed. Naturally, their mistreated mental illness serves as a foundation and map to their futures; often dysfunctional and possibly destroyed. Any combination of academic, legal, social, behavioral and family issues too often follow. When economic and support system issues are also prevalent, the effects are what I find to be a public health problem. Dr Mota-Castillo seemed to be pointing out that this issue revolves around TRUE diagnosis. I see this continually missed by psychiatrists, though all too often the diagnosis is made by primary physicians. Teachers are satisfied and parents often feel trapped into forcing children to take amphetamines to control their childs behavior in school. Even the most informed parents (and teachers) are at the mercy of doctors. Have you ever taken an amphetmamine? Almost anybody will find themselves more focused and "controllable". The side effects I witness daily are what finds me seeing this mistreatment as harmful and abusive, theleast of which are insomnia and weight loss (due to effect on appetite. High school students to college students to adults purposely use this drug illicitly to study, stay awake, or lose weight. Trust me on this. Whatever your stake or commitment to amphetamines, is the question of misdiagnosis and mistreatment of ADHD not worth our children, who have no voice in this?

"...I see it as a teaching moment for those that believe that foreigners think with an accent. When I read her questioning to the Board of Psychiatry and Neurology for certifying individuals with English as second language..."

Dr. Mota-Castillo, I think you read what wasn't there? This is so annoying, because I just KNEW that you or someone else would do that. That was why I wrote, so very clearly, "I'm not writing this out of any kind of racism or hostility towards people who are ESL speakers." I don't even know what it means to think all foreigners "think with an accent." Do you mean that I imagine the voice of Javier Bardem every time you write something. Or that you sound like some creature out of a Guillermo Del Toro film?

I don't even know why I would have to clarify anymore. This was about people with limitations on their English who work in professions where communication is essential. I even used the phrase "people with limited English." I wrote it like that on purpose! I was so clear that this was not an ESL discussion for me.

If it makes you feel less singled out because of your ESL pdoc status, I attended a college where ESL students were statistically more likely to pass their college level English courses than students who were native speakers. I also had two roommates when I was in the dorms who were ESL students. One was an English major who moved to America as a teenager in high school. I did not hear one hint of her Israeli accent. She was totally California, and had a 3.9 GPA. She only got one A- in an English course.

I lived in Los Angeles for years, which has a high number of immigrants and ESL speakers. There were many who had no hint of a foreign accent.

This has nothing to do with certifying ESL pdocs. It has to do with standards.

For example, last I checked, there is only one deaf band in the entire world. And they are a very good rock band. The drummer was told as a child that he could never play an instrument by his parents. This made him sad, because all of his other siblings were playing instruments. So he decided that he would be a drummer. He can't hear a thing, but he's amazing.

That is discrimination to tell deaf people they can't form bands or play instruments. It's just that being deaf is kind of a hard handicap to work around when your a musician, so it doesn't surprise me that there is only one all-deaf band where they are actually able to get jobs as a band.

I don't set the standards for board certification in psychiatry. Personally, I would want it higher. And it has nothing to do with ESL. You could be a native speaker and have communication difficulties because of chronic pain conditions, high distractibility, traumatic brain injury, and whatever else would inhibit someone. Even being deaf could prevent someone from working in psychiatry if the person wasn't able to work around it well enought.

The issue on the table is that many professionals diagnose “hyperactive and inattentive” children as having ADHD without ruling out other conditions…many of them, not just mood disorders.I am not going to change the focus from that important issue because when a child with severe obsessions is given an amphetamine his real problem is going to get worse. Still I want to thank you for the laugh because your statement reminded me of this famous phrase: I am not a crook.

SHE RESPECTFULLY MAKES HER POINT THAT YOUR FIELD DHOULD HAVE HIGHER STANDARDS WHEN IT COMES TO COMMUNICATION SKILLS, AND ALL YOU DO IS LAUGH AND CONDESCEND

SHAME ON YOU!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

As an FYI, there are many psychiatrists who speak perfect English who have no business practicing medicine. In my opinion, the issue we should be focusing on is that just like stimulants, bipolar meds are way over prescribed to kids. No, this is not an issue of being a denier, antipsychiatry, scientologist, etc. as many psychiatrists feel the same way.

Anyway, I think Pseudo Kristen asked some very good questions about the examples Dr. Mota-Castillo gave that haven't been addressed by him. Yes, I know that a blogger isn't under the obligation to respond to anything. But I find it interesting that he is getting into a tit for tat exchange on grammar issues and not addressing the issues she raised.

I agree that Peudo Kristen had the best response so far. When I read the scenerios, they all indicated to me that the children should be taken off stimulants and observed, since stimulants could account for most of the symptoms.

I do not "get" why a child must have some sort of mental illness diagnosis, just because the parents have dragged the child into a psychiatrist. Recasting the effects of amphetimes as BiPolar disorder strikes me as bad as misdiagnosiing ADHD.

When I was teaching I had a high school senior student who was diagnosed as ADHD and on amphetimes. As I delved into his learning disabilty I discovered he was nearly blind due to a congenital condition as an extreme premature baby. While working with him, I discovered that he was a very slow learner. He could focus, but he still could not learn, even when material was presented over, and over in different ways. Then he had additional learning difficulty because he arrived at school late, missing his first class and usually half of his second, and though his father complained about his son's grades, his father would not get his son to school on time. In repeated meetings with teachers the father was verbally abuse to his son and the teachers. My student made two suicide attempts in his senior year, AT SCHOOL. While some might want to immediately rediagnose this boy as Bipolar, I would hope that someone got him off the stimulates, and helped him to learn to live with his visual diability and his inability learn well, and go from there. I do not know the end of the story. He ended up on a psych ward twice due to the suicide attempts, and he likely ended up on more drugs, not less.

I agree with AA that it's interesting that he chose to respond to my comments and no one elses. And there are plenty of doctors who speak perfect English and practice horrible medicine, but then I never said that I thought English was the only standard that needed to be met for being a psychiatrist.

And I also would like to state that I never claimed to laugh at his comments or questioned his morality. It's even a little weird for me, because he says he is a grandfather...and I feel like he's too old to be doing that. It's like something out of Mean Girls or Heathers. I actually don't think I make personal attacks on him, though he claims that is what I am doing. Everything I've written has been about psychiatry, standards, and board certification. You will not see anything in my posts about his character.

Anyway, I don't normally talk about this, but I have HFA. It's kind of a worthless diagnosis. For me it's like, Why even bring it up? I reported it to a pdoc not long ago. His response was that he couldn't medicate me for that and so he diagnosed Bipolar Type 2. I stopped seeing him. But really, that is actually the typical reaction, because the average pdoc I have met is a deer in the headlights when confronted with an autistic patient. They freak out, don't know how to medicate/deal with it, and come up with a mood disorder so they can match drugs to a diagnosis. They would rather make you ADHD, Bipolar, OCD, whatever. I have also met so many Autistic people with a Borderline Personality Disorder diagnosis. It's like the trendy thing now to explain moodiness in HFA people.

But I don't have ANY problem with anyone with autism describing themselves as having ADHD or taking stimulants. I have an ADHD PI diagnosis, and stimulants did not work out for me. I have met some autistic people who have prescriptions for stimulants and they say it works for them. This is not the first time that I have heard autisitc people do not respond well to stimulants, but I have also heard from a clinician that, in his experience, a lot of autistic people just don't respond well to any psychiatric drug. They get paradoxical reactions to benzos, aggressive on antidepressants, paranoid on atypical antipsychotics, etc.

Personally, I think ADHD is useful in autism for psychotherapy reasons. I think the help that is out there for ADHD is actually pretty helpful. I find the books on how to manage your life with an ADHD brain to be very helpful as well.

But I don't think stimulants should be pushed on any kid if it's not working out. If a parent wants an autistic kid to receive ADHD counseling in order to cope with short term memory problems, disorganization, moods, whatever, then I think that is fine. There is more help available for that than there is with autism.

Parents are always the biggest factor in helping a kid. My mom sure clocked the man hours! She didn't care how hard it was gonna be. She was drilling me on the alphabet every single night, reading to me, walking me through homework...

I don't even tell most people, outside of close family and some friends, that I have HFA. I just chalk up my peculiarties to an ADHD brain and it works just fine for me. When you say autism people think your retarded or can't believe you actually know where you are. It's just too bad the stimulants didn't work out for me.

This is kind of distressing. I've been studying for the psych boards and I got a question from boardvitals.com about ADHD in a young person, but I ended up answering incorrectly. Looks like I'm justified, because I picked bipolar disorder, but this makes me nervous about how questions are written on these exams. Thanks for the informative post! -K